Ebook Differential diagnosis in ultrasound (2nd edition): Part 1

(BQ) Part 1 book Differential diagnosis in ultrasound presents the following contents: Chest, neck lesions, hepatobiliary system and abdomen, spleen, pancreas, gastrointestinal tract, retroperitoneum, renal, urinary bladder, adrenal gland.

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Differential Diagnosis

in

ULTRASOUND

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Subharti Medical College Meerut, Uttar Pradesh, India

Satish K Bhargava

MBBS MD (Radiodiagnosis)

MD (Radiotherapy) DMRD FICRI FIAMS FCCP FUSI FIMSA FAMS

Professor and Head Department of Radiology and Imaging

School of Medical Sciences and Research

Sharda Hospital Sharda University, Greater Noida, Uttar Pradesh, India

Formerly, Professor and Head

Department of Radiology and Imaging

University College of Medical Sciences

(University of Delhi) and GTB Hospital, Delhi, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • Panama City • London • Dhaka • Kathmandu

Second Edition

®

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Jaypee Brothers Medical Publishers (P) Ltd

4838/24, Ansari Road, Daryaganj

New Delhi 110 002, India

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only While every effort is made to ensure a accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application

of any of the contents of this work If not specifically stated, all figures and tables are courtesy

of the editors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.

Differential Diagnosis in Ultrasound

First Edition: 2005

Second Edition: 2013

ISBN 978-93-5025-999-3

Printed at

Jaypee Brothers Medical Publishers (P) Ltd

17/1-B Babar Road, Block-B, Shaymali

Email: jaypee.nepal@gmail.com

Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama

Phone: +507-301-0496 Fax: +507-301-0499

Email: cservice@jphmedical.com

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My loving late wife Kalpana

Whose inspiration and sacrifice have made possible to bring out this book

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Anoop Kumar Durga Das

(University of Delhi) and

GTB Hospital, Delhi, India

Anurag Agarwal

Additional Director

National Board of Examination

Ansari Nagar, New Delhi, India

Ashish Verma

Assistant Professor

Institute of Medical Sciences

Banaras Hindu University (BHU)

Varanasi, Uttar Pradesh, India

Contributors

Avneesh Kumar Singh

Senior Resident Department of Radiodiagnosis and Imaging

All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi, India

Gopesh Mehrotra

Professor Department of Radiology and Imaging

University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India

Mamta Motla

Ex Senior Resident Department of Radiology and Imaging

University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India

Meenakshi Prakash

Resident Department of Radiology and Imaging

University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India

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Pardeep Kumar

Senior Resident

Maulana Azad Medical College

and Associated GB Pant Hospital

New Delhi, India

Pushpender Gupta

Department of Radiology

Wake Forest University Baptist

Medical Center, Medical Center

(University of Delhi) and GTB

Hospital, Delhi, India

Presently,

Yash Diagnostic Center

Civil Lines, Moradabad

Uttar Pradesh, India

University College of Medical Sciences (University of Delhi) and GTB Hospital

Delhi, India

Sumeet Bhargava

Assistant Professor Department of Radiology and Imaging

Subharti Medical College Meerut, Uttar Pradesh, India

Swati Gupta

Thingujam Usha

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Preface to the Second Edition

With the feedback from the practicing selenologists andresidents, more text and illustrations have been added so

as to make this book more handy for better interpretation

at bedside I am sure the book in the present format will

be more acceptable and useful to the residents, sonologistsand practitioners in their day-to-day practice

Sumeet Bhargava Satish K Bhargava

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Since the introduction of ultrasound (US), this modalityhas evolved from its primitive nature to its presentglamorous status Its popularity in radiology has alwaysbeen due to its cost-effectiveness, easy availability andnoninvasive nature Its diagnostic role has been explored

in every organ system and its usefulness felt every time.Its support in therapeutic techniques is unparalleled.Radiology without ultrasound is unimaginable

Almost always realtime US is the initial investigativetool in the radiology department Many a time, thismodality is enough to establish a diagnosis and alwaysprovides a direction for further evaluation Its uniquenesslies in its operator-dependent nature As the ultrasonologistscans through the region of interest, recognition andinterpretation of the important findings are important forestablishing and imaging diagnosis It is also imperative toknow the various conditions producing a particularsonographic finding Only ultrasound can be judiciouslyused to answer the question posed to the radiologist Thisbook is a special effort to provide a concise knowledge ofthe differential diagnosis of a sonographic finding A list ofthe various clinical conditions and their short description

is the main feature of the text The information has beenkept concise and unnecessary repetition avoided Linediagrams and illustrations have been added to support thetext The aim of this book is to assist the sonologist withlogical interpretation of the scan I hope this attempt willprove useful to all practicing sonologists

Sumeet Bhargava Satish K Bhargava

Preface to the First Edition

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I am grateful to my colleagues and friends who gavetimely support and stood solidly behind me in our jointendeavor of bringing out this book which was requiredkeeping in view of wide acceptability of ultrasound indeveloping countries My special heartfelt thanks are due

to the sincere and hardworking staff of M/s JaypeeBrothers Medical Publishers (P) Ltd, New Delhi, India,particularly, Shri Jitendar P Vij (CEO), Mr Tarun Duneja(Director-Publishing), Ms Samina Khan and Mr KKRaman (Production Manager) It is indeed the result ofthe hardwork of the staff of M/s Jaypee Brothers MedicalPublishers (P) Ltd and the contributors who have alwaysbeen in keen desire to work with smiling faces and withpolite voices as a result of which this book has seen thelight of day

Acknowledgments

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1 CHEST 1 1.1 Chest Overview 1

Pushpender Gupta, Satish K Bhargava

1.6 Vascular Lesions of Mediastinum 18

Sumeet Bhargava, Pardeep Kumar, Satish K Bhargava

1.7 Cystic Masses of Mediastinum 19

Sumeet Bhargava, Satish K Bhargava

1.8 Diaphragm 21

Satish K Bhargava, Pushpender Gupta

2 NECK LESIONS 29 2.1 Thyroid 29

2.1.1 Solitary Thyroid Nodule 29

Satish K Bhargava, Avneesh Kumar Singh, Pushpender Gupta

2.1.2 Carcinomas 41

Sumeet Bhargava, Satish K Bhargava, Avneesh Kumar Singh

Contents

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2.1.5 Cystic Thyroid Nodule 49

Satish K Bhargava, Sumeet Bhargava, Pushpender Gupta

2.2 Salivary Gland 52

Pushpender Gupta, Satish K Bhargava

2.2.1 Enlargement of Salivary Gland 52

Satish K Bhargava, Pushpender Gupta, Gopesh Mehrotra

2.3 Neck Masses 59

Satish K Bhargava, Sumeet Bhargava

2.4 Cervical Lymphadenopathy 69

Satish K Bhargava, Rajul Rastogi

3 HEPATOBILIARY SYSTEM AND

ABDOMEN 74 3.1 Generalized Increase in

Liver Echogenicity 74

3.2 Generalized Decrease in

Echogenicity of Liver 81

Sumeet Bhargava, Satish K Bhargava, Swati Gupta

3.3 Solitary Echogenic Liver Mass 83

3.4 Shadowing Lesions of Liver 90

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3.5 Hepatoma, Bull’s Eye or Target

Lesion of Liver 93

3.6 Periportal Hyperechogenicity of Liver 95

3.7 Periportal Hypoechogenicity 97

3.8 Focal Hypoechoic Lesions 98

Pardeep Kumar, Satish K Bhargava

3.9 Cystic Lesions of Liver 104

Pardeep Kumar, Satish K Bhargava

3.10 Mixed Cystic and Solid Lesions 120

Satish K Bhargava, Pardeep Kumar

3.11 Patterns of Hepatic Metastasis 127

Satish K Bhargava, Pardeep Kumar

3.12 Nonvisualization of Gallbladder

on Ultrasound 132

3.13 Diffuse Gallbladder Thickening 136

3.14 Focal Gallbladder Thickening 141

3.15 Echogenic Fat in Hepatoduodenal

Ligament 148

3.16 Congenital Biliary Cyst 148

3.17 Differential Diagnosis of

Pericholecystic Fluid 150

Ashish Verma, Satish K Bhargava,

Sumeet Bhargava

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Satish K Bhargava, Ashish Verma, Sumeet Bhargava

3.20 Abdominal Wall Masses 157

Satish K Bhargava, Ashish Verma, Sumeet Bhargava

Ultrasound 183

4.2 Cystic Lesion of Spleen 184

4.3 Solid Splenic Lesion 191

4.4 Hyperechoic Splenic Lesion 196

5 PANCREAS 199 5.1 Differential Diagnosis of Cystic

Pancreatic Masses 199

Sumeet Bhargava, Satish K Bhargava,

Ashish Verma, Rajul Rastogi

Solid/Complex Lesion 203

Satish K Bhargava, Sumeet Bhargava, Ashish Verma

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6 GASTROINTESTINAL TRACT 211 6.1 Ultrasound Differential

6.5 Small Bowel and Colon 222

Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi

6.6 Differential Diagnosis of Acute

Appendicitis (Appendiceal Lesions) 235

Anoop Kumar Durga Das

6.7 Role of Rectal Endosonography 241

Satish K Bhargava, Sumeet Bhargava,

Meenakshi Prakash, Anoop Kumar Durga Das

7 RETROPERITONEUM 243 7.1 Differential Diagnosis of

Solid Masses 243

Ashish Verma, Satish K Bhargava, Sumeet Bhargava

Pseudomasses 250

Ashish Verma, Sumeet Bhargava, Satish K Bhargava

7.3 Differential Diagnosis of Cystic

Lesions and Fluid Collection 251

Sumeet Bhargava, Satish K Bhargava, Ashish Verma

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8 RENAL 253 8.1 Differential Diagnosis of Renal

Pseudotumor 253

Satish K Bhargava, Rajul Rastogi, Ashish Verma

8.2 Differential Diagnosis of Cystic

Renal Disease 255

Complex/Solid Renal Masses 261

Satish K Bhargava, Ashish Verma, Rajul Rastogi

8.4 Differential Diagnosis of Hypoechoic Renal Sinus 267

Ashish Verma, Satish K Bhargava, Rajul Rastogi

8.5 Differential Diagnosis of Hyperechoic Renal Nodules 268

Ashish Verma, Satish K Bhargava, Shuchi Bhatt

8.6 Differential Diagnosis of Dilated

Pelvicalyceal System and Ureter 270

Sumeet Bhargava, Ashish Verma,

9 URINARY BLADDER 279 9.1 Differential Diagnosis of

Bladder Wall Thickening 279

9.2 Differential Diagnosis of Bladder

Contour and Caliber Abnormality 286

10 ADRENAL GLAND 290 10.1 Bilateral Large Adrenal Gland 290

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10.2 Unilateral Adrenal Masses 293

10.3 Large Solid Adrenal Masses 297

10.4 Cystic Adrenal Masses 299

10.5 Adrenal Pseudomasses 300

11 PERITONEAL AND MESENTERIC

MASSES 301 11.1 Round Solid Masses in Mesentery 301

11.2 Ill-defined Mass 303

11.3 Loculated Cystic Peritoneal Masses 310

11.4 Solid Peritoneal Lesions 312

12 SCROTUM 322 12.1 Differential Diagnosis of

Acute Scrotum 322

Scrotal Calcification 328

12.3 Differential Diagnosis of Scrotal Gas 332

Satish K Bhargava, Rajul Rastogi, Ashish Verma

Scrotal Masses 332

Rajul Rastogi, Ashish Verma

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13 TESTIS AND EPIDIDYMIS 341 13.1 Differential Diagnosis of Cystic

Testicular Lesions 341

13.2 Pediatric Testicular Masses 345

Sumeet Bhargava, Ashish Verma, Satish K Bhargava

Epididymal Lesions 350

14 PROSTATE 354 14.1 Differential Diagnosis of Prostatic Cyst 354

Satish K Bhargava, Sumeet Bhargava, Rajul Rastogi

14.2 Müllerian Cyst 354

Satish K Bhargava, Sumeet Bhargava, Rajul Rastogi

14.3 Ejaculatory Duct Cyst 356

Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava

14.4 Seminal Vesicle Cyst 357

Satish K Bhargava, Ashish Verma,

Sumeet Bhargava, Rajul Rastogi

14.5 Hypoechoic Lesions 358

Rajul Rastogi, Anubhav Sarikwal, Sumeet Bhargava

15 BREAST 364 15.1 Cystic Lesions 365

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the Synovium 389

Rajul Rastogi, Satish K Bhargava

16.2 Cystic Mass in Popliteal Fossa 389

16.3 Hip Joint Effusion in Adults 390

16.4 Proliferative Synovitis 391

16.5 Tendon Tears 391

16.6 Pediatric Hip Joint—An Overview 393

17 ORBIT 418 17.1 Orbital Pathologies 443

Satish K Bhargava, Ashish Verma, Anubhav Sarikwal

17.2 Low Reflectivity Lesions 443

Satish K Bhargava, Ashish Verma, Anubhav Sarikwal

17.3 Medium Reflectivity Lesions 444

Satish K Bhargava, Ashish Verma

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17.4 High Reflectivity Lesions 444

17.8 Differential Diagnosis of Orbital

18 NEONATAL AND INFANT BRAIN 459 18.1 Cystic Lesions 459

Shuchi Bhatt, Satish K Bhargava

18.2 Solid Lesions 461

18.3 Prominent Choroid Plexus 462

18.4 Destructive Lesions of Brain 463

18.5 Ventriculomegaly 467

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18.6 Congenital and Developmental

Malformations 472

18.7 Infective Cystic Lesions 477

18.8 Vascular Lesions 479

Anubhav Sarikwal

18.9 Traumatic Cystic Lesions 480

Anubhav Sarikwal

18.10 Intracranial Hemorrhage 481

18.11 Asphyxia 484

18.12 Solid Infective Lesions 486

18.13 Tumors 487

18.14 Congenital Intracranial Infection

of Infant and Children 487

18.15 Meningitis 490

18.16 Enlarged Choroid Plexus 492

19 NEONATAL AND INFANT SPINE 493 19.1 Spinal Dysraphism 493

Shuchi Bhatt

19.2 Spina Bifida Aperta 495

Shuchi Bhatt

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19.3 Spina Bifida Cystica 496

Satish K Bhargava, Shuchi Bhatt

20.2 Cystic Pelvic Masses 515

Satish K Bhargava, Shuchi Bhatt, Meenakshi Prakash

20.3 Complex Pelvic Mass 520

Satish K Bhargava, Shuchi Bhatt, Thingujam Usha

20.4 Solid Pelvic Masses 523

Satish K Bhargava, Shuchi Bhatt

20.5 Adnexal Masses 524

Satish K Bhargava, Shuchi Bhatt,

Anoop Kumar Durga Das, Swati Gupta

20.6 Ovarian Tumors 535

Satish K Bhargava, Shuchi Bhatt, Meenakshi Prakash

20.7 Uterine Masses 542

Shuchi Bhatt, Thingujam Usha, Sumeet Bhargava

20.8 Diffuse Uterine Enlargement 551

Shuchi Bhatt, Anoop Kumar Durga Das

20.9 Thickened Endometrium 552

Shuchi Bhatt, Sumeet Bhargava, Swati Gupta

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Thickened Placenta 569

20.11 Ultrasound Signs of Chromosomal

Abnormality 571

20.12 Absent Pregnancy Test with

Absent Intrauterine Pregnancy 576

20.13 Fetal Causes of Abnormalities

in Liquor Volume 577

Ashish Verma, Satish K Bhargava

20.14 Intra-abdominal Fetal Calcification 582

20.15 Differential Diagnosis of Fetal

Thoracic Abnormalities 586

20.16 Unsuccessful First Trimester Pregnancy 589

20.17 First Trimester Bleeding 592

Satish K Bhargava, Ashish Verma, Shuchi Bhatt

20.18 Fetal Hydrops 597

20.19 Twin Pregnancy/Multifetal Pregnancy 601

20.20 Differential Diagnosis of Echogenic

Fetal Kidneys 605

20.21 Differential Diagnosis of Syndromes

Associated with Renal Malformations 607

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Fetal Hydronephrosis 608

20.23 Fetal Head, Neck and Face 614

20.24 Differential Diagnosis of Micrognathia 615

Associated with Hypertelorism 616

Associated with Frontal Bossing 618

20.27 Differential Diagnosis of Syndromes Associated with Craniosynostosis and other Causes 618

20.28 Differential Diagnosis of Cleft Lip

with/without Cleft Palate 620

20.29 Differential Diagnosis of Conditions

Associated with Facial Clefting 621

20.30 Fetal Central Nervous System 624

20.31 Fetal Abdominal Wall Defects 635

20.32 Nuchal Fold and Translucency 637

20.33 Prenatal Sonographic Diagnosis

of Cardiac Anomalies 637

INDEX 647

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1.1 CHEST OVERVIEW

Ultrasound is a noninvasive, relatively inexpensive andmost rewarding imaging modality, carries no radiationburden, but not much exploited for evaluation of chestdisease because of basic (inherent) properties of US wavesnot to pass through bony cage and air-filled lungs.However, over a couple of years, US has emerged as auseful tool in evaluating wide range of perplexing clinicalproblems of chest due to presence of fluid in pleuralspace, consolidating or atelectatic lung or even tumor,provide window for US to penetrate and this has helped

in diagnosis of certain conditions or limit the DD ofconditions under consideration

1 Chest wall (Fig 1.1.1): It has helped in diagnosing softtissue abscesses, masses, osteomyelitis, rib tumors andeven fracture where plain X-ray gives only soft tissueswelling or obliteration of costophrenic angle (may bedue to pleural fluid or sometimes by rib tumor) andalso where rib erosion is due to underlying carcinoma.Sometimes, when clinically mass is suspected withfractures, US can be used as a first modality particularly

in children to avoid radiation by getting an X-raychest

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2 Mediastinum: Anterior mediastinum can be very evaluated by US through suprasternal route byelevating shoulders and extending the neck This willavoid structures particularly thymus in children Evenparatracheal and hilar adenopathy can be diagnosedespecially in tubercular patients where it is not onlyhelpful in diagnosis but also in follow-up when child

well-is on antitubercular therapy, thus avoiding unnecessaryradiation and getting repeated X-rays

3 Lung parenchyma: It is also helpful in differentiatingcystic lesions of the lung parenchyma like hydatidcyst (Fig 1.1.2) consolidation (Figs 1.1.3 to 1.1.5),collapse and tumor of lung Also differentiates a tumorand pleural fluid/consolidation above the diaphragmfrom (subpulmonic effusion) below the diaphragm

4 Pleura: US is a good modality to differentiate pleurallesions from parenchymal ones It is also helpful in

Fig 1.1.1: Normal lung as seen in transverse section Ribs with

distal shadowing are shown with intercostal muscles The lung pleural interface is seen as an echogenic line

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Fig 1.1.2: Lung hydatid seen as anechoic cystic lesion in

transverse scan of lung

lesion with air bronchogram in right lower lobe of lung

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Fig 1.1.4: US scans showing consolidation with cavitation in

lower lobe

Fig 1.1.5: US scans show lobar consolidation with presence of

color flow on CDFI

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diagnosing minimal amount of fluid in pleural cavity,even 5-10 ml of fluid, thus avoiding need of lateraldecubitus film/lateral chest film.

i It also gives the etiology of pleural fluid due to itsappearance as anechoic, hypoechoic, echogenic,presence of debris, nodules and types of septa

ii Anechoic—all transudates are anechoic, however,all anechoic collections are not transudates Aboutone-third of exudative collection tends to beanechoic in the beginning

iii Hypoechoic—usually exudative effusions,empyema and later stages of hemothorax

iv Echogenic—hemothorax or empyema

v Debris—represents settled down pus cell, bloodcells, etc

vi Septations—usually represent process of loculationand fibrosis occurring in pleural effusion Thinclean septa with no or very minimal debris-tubercular pleural effusion However, thick, shaggyirregular septations with debris-pyogenic effusion.vii Pleural nodule/masses (Fig 1.1.6), represent meso-thelioma, metastatic nodule and tuberculomata Inaddition to characteristics septations the thickness

of parietal pleura and combined (parietal + visceral)also give etiological diagnosis As tubercularpleural effusion-parietal pleural thickness varies2-8 mm and combined pleural varies from 4-10

mm In pyogenic pleural effusion-parietal pleuralthickness varies from 5-22 mm and combined 8-27

mm In hemothoraces (post-traumatic) thickirregular mantle of pleura around hypoechoicpleural collection is seen, pleural thickness variesfrom 12-18 mm

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Fig 1.1.6: US scans show pulmonary mass with color flow associated

with mild pleural effusion causing compression atelectasis of underlying parenchyma and hepatic metastases

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Pleural effusion v/s ascites: Bare area sign—if fluid interface

is abutting the bare area of liver than it is pleural effusionand if it is not than it is ascites

Diaphragmatic crus sign—pleural effusion is lateral and superior to crus of diaphragm while ascites isanteromedial and inferior to crus of diaphragm

postero-5 Intervention: US is very helpful in fine needleaspiration biopsy, pleural tapping, guided pleuralaspiration and tube placement

6 ICU: US is very helpful in critically ill-patients that istrauma and ICU-needs serial X-rays to see day-to-daychanges in lesions like consolidation and lung abscess(Fig 1.1.7), particularly when there is inability toposition the patient as required and usuallysubstandard quality of X-rays

Fig 1.1.7: Lung abscess—a large predominantly hypoechoic SOL

with internal septae and posterior enhancement is seen in lower lobe of right lung Aspiration revealed pus Inversion of diaphragm

is seen

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• Good guidance tool

• Repeated evaluation with no radiation cost

Ability to detect abdominal lesions associated withcausative of chest lesion as liver abscesses leading topleural effusion

• Fluid with floating echodensities

• Septations—thick and shaggy (Figs 1.2.1A to C)

• Fibrin strands

• May be anechoic fluid

• Echogenic fluid (Fig 1.2.2)

• Pleural nodules

• Thickened pleura

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Figs 1.2.1A to C: (A) Pleural effusion superior to the diaphragm;

(B) Pleural effusion and ascites outlining the diaphragm; (C) Ascites only Irregular outline of the gut is seen due to ascites

Causes of Transudative Pleural Effusion

1 Increased hydrostatic pressure

– Congestive heart failure

– SVC obstruction

– Constrictive pericarditis

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Fig 1.2.2: Longitudinal intercostal view in a patient with pleural

effusion showing echogenic surface of visceral and perietal pleura

2 Decreased osmotic pressure

– Cirrhosis with ascites

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Fig 1.2.3: Longitudinal intercostal view—pleural effusion and

collapsed lung showing echogenic gas-filled bronchus (arrow) within the collapsed lung

Fig 1.2.4: Loculated multiseptated fluid collection seen in the

pleural cavity with associated pleural thickening

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